Institutional ethnography: A methodology for exploring complex problems in healthcare systems.

Healthcare professionals experiencing barriers in the delivery of care are often unaware of factors within complex institutions that create and perpetuate those problems. Institutional ethnography in healthcare is a research methodology that starts from the perspective of a problem that clinicians or people receiving care experience and seeks to identify how those negative experiences are coordinated by institutional structures. This paper describes and advocates for the use of institutional ethnography as a powerful tool to investigate problems experienced by individuals or groups in the complex systems of healthcare design and delivery. It is a research methodology that has been adopted across settings in North America, although it has the potential to be utilized more broadly across other settings by clinicians and researchers. This echoes calls from other authors for its use across a wider range of healthcare disciplines and settings. Institutional ethnography is an underutilized research methodology that has potential to address a wide range of challenges experienced in contemporary healthcare. It offers healthcare clinicians the opportunity to better understand and resolve issues affecting their practice within complex healthcare systems.

Clinical nurse managers' leadership practices in Saudi Arabian hospitals: A descriptive cross-sectional study.

AIM: To understand the situational profiles of clinical nurse managers' transformational leadership practices in Saudi hospitals. BACKGROUND: Clinical nurse managers' effective leadership may enable registered nurses to provide safe patient care. METHODS: This included 29 clinical nurse managers and 318 registered nurses from three Saudi hospitals. Data were collected using the leadership practice inventory-self and the leadership practice inventory-observer. RESULTS: A significant difference between self- and observer-assessed transformational leadership practices of clinical nurse managers was found. There was also a significant difference in transformational leadership practice between Saudi and non-Saudi clinical nurse managers. Ward experience of clinical nurse managers was statistically positively associated with higher ratings of "enabling others to act". Length of clinical nurse managers' experience was associated with "enabling others to act" and "encouraging the heart" practices. CONCLUSION: Clinical nurse managers rated their transformational leadership performance higher than that reported by registered nurses. Further, non-Saudi clinical nurse managers working in Saudi hospitals overestimated the extent of their transformational leadership practices. IMPLICATIONS FOR NURSING MANAGEMENT: Clinical nurse managers should gather feedback about their leadership performance regularly and implement required changes. Hospital administrations should provide additional support to clinical nurse managers through effective leadership programmes, enculturation and team-building strategies, to create a shared vision regarding the execution of optimal leadership.

Regulation, migration and expectation: internationally qualified health practitioners in Australia-a qualitative study.

BACKGROUND: The global movement of internationally qualified health practitioners (IQHPs), seeking to live and work outside of their place of origin, is subject to considerable study and scrutiny. Extensive published material exists, from government enquiries and print news media articles to peer-reviewed papers, reporting on the views and impacts of migration and practitioner registration. Unsurprisingly much of the research focuses on the two largest groups of health professionals, international medical graduates (IMG) and internationally qualified nurses (IQN). This paper presents a unique case study examining the challenges and complexities of navigating the regulatory processes for skilled migration and practitioner registration in Australia. DISCUSSION: The study comprised a review and analysis of the current policy frameworks, standards and assessment models applied by regulators affecting skilled migration and registration of IQHPs. To target the triangulated themes of regulation, experience and expectations, a phenomenological component was also conducted with the mapping of shared experiences of four key participant groups comprising the following: assessors operationalising the current policies and processes governing skilled migration and registration, educators offering preparatory and training programs to IQHP, workforce agencies engaging with and recruiting IQHP and internationally qualified doctors, nurses and midwives. The study was informed by rich qualitative data extracted from twenty-eight in-depth semi-structured participant interviews. Key themes and points of intersection between participant experiences and the regulatory frameworks were identified using theory and data-driven coding and thematic analysis via the NVivo 12 plus software. CONCLUSION: From studying the complexities of the current regulatory processes for skilled migration and practitioner registration and informed by participants with first-hand knowledge and experience, this research found a clear argument for a re-examination and update of the current regulatory requirements for IQHP. Without greater innovation, harmonisation, evidence-based solutions and reform, it is likely that Australian regulators, policymakers, employers, and the nursing, midwifery and medical professions at large will continue to experience challenges in registering, employing and supporting IQHP, while maintaining the safety of the public requiring care in the Australian healthcare system.

Instruments measuring behavioural aspects of the nurse-patient relationship: A scoping review.

AIMS AND OBJECTIVES: To identify and map tools measuring behavioural aspects of the nurse-patient relationship. BACKGROUND: The behaviours nurses employ to develop relationships with patients form a key part of nursing practice. Systematically measuring these behaviours provides an objective means of assessing and evaluating how nurses establish and maintain relationships with patients in a variety of settings. Whilst tools exist to measure these behaviours, little is known about their aims/scope, structure, method of development and contexts of use. Such knowledge is crucial for understanding the nature of the literature, including in which contexts and for which patient groups existing tools are suited. DESIGN: Scoping review informed by Joanna Briggs Institute methodology. METHODS: A database search was undertaken using CINAHL, PsycINFO, Pubmed and Embase. Primary research articles, theses and methodological papers that developed, refined and/or administered tools measuring behavioural aspects of the nurse-patient relationship, in any setting and for any patient group, were included. Tools had to measure actual not hypothetical behaviour (e.g., perceptions regarding importance). Data from included studies and tools were mapped. Results are reported in accordance with PRISMA-ScR guidelines. RESULTS: One hundred and twenty-seven studies, containing 35 tools, were included. The literature was characterised by substantial variability, stemming from the continued refinement of tools (e.g., reduction to short forms) but also the development of new tools that appeared to duplicate existing work and the inconsistent use of tools across studies. CONCLUSIONS: The volume of tools available demonstrates the importance of measuring the nurse-patient relationship. However, the existing duplication and variability create challenges in choosing amongst the tools available and show that, as a concept, the nurse-patient relationship remains poorly understood. RELEVANCE TO CLINICAL PRACTICE: Research is required to synthesise, and assess the quality of, existing tools, enabling clinicians, leaders/managers, educators and researchers to administer appropriate tools to evaluate the nurse-patient relationship.

The Complexities of Everyday Life and Healthcare Utilization in Danish Children With ADHD: A Mixed Methods Study.

PURPOSE: To explore and describe everyday life and hospital-based healthcare experiences and utilization in families of children with ADHD in Denmark. DESIGN AND METHODS: The present work is a multistage, mixed methods study. The design consists of three individual studies: a meta-synthesis, a focused ethnographic study, and a historical cohort study. RESULTS: The integrated findings show that: 1) parental stressors affect everyday life and hospital-based service use; 2) parents have concerns for their child from early childhood and fight to have their concerns recognized; and 3) healthcare professionals are important for parents to navigate the persistent challenges of everyday life. CONCLUSIONS: Having a child with ADHD pervades everyday life and children with ADHD use more medical and psychiatric services in hospitals during the first 12 years of life than children without ADHD. The findings demonstrate a vulnerable everyday life experience and highlight the importance of the families being recognized, accepted, and respected in hospital-based healthcare services from early childhood. PRACTICE IMPLICATIONS: Healthcare professionals need to recognize the challenges the family of a child with ADHD faces and to acknowledge that ADHD pervades all aspects of everyday life and all other healthcare issues. It is important for healthcare professionals, regardless of specialty, to engage with individual families and to positively contribute to the medical and psychiatric healthcare experience.

Attention Deficit Hyperactivity Disorder in Childhood: Healthcare Use in a Danish Birth Cohort during the First 12 Years of Life.

OBJECTIVES: To compare the mean number of medical and psychiatric hospital-based services in children with and without attention deficit hyperactivity disorder (ADHD) and to assess the effect of ADHD on hospital-based service use, including child-, parental-, and socioeconomic-related risk factors. STUDY DESIGN: A Danish birth cohort was followed through 12 years, and children with ADHD were identified using Danish nationwide registries. Poisson regression analyses were used to assess the association of ADHD with service use and to adjust for a comprehensive set of explanatory variables. RESULTS: Children diagnosed with ADHD used more medical and psychiatric hospital-based healthcare than those without ADHD. In children with ADHD, intellectual disability and parental psychiatric disorder were associated with increased medical and psychiatric service use. Low birth weight and low gestational age were associated with increased medical service use. Psychiatric comorbidity and having a divorced or single parent were associated with increased psychiatric service use. CONCLUSIONS: ADHD independently affected medical and psychiatric hospital-based service use even when adjusting for a comprehensive set of explanatory variables. However, the pattern of medical and psychiatric hospital-based service use is complex and cannot exclusively be explained by the child-, parental-, and socioeconomic-related variables examined in this study.

ADHD and Everyday Life: Healthcare as a Significant Lifeline.

AIM: The aim of this qualitative study was to explore parental experiences of how healthcare practices and healthcare professionals in hospital clinics in Denmark influence everyday life of parents with a child with ADHD. DESIGN AND METHODS: The methodology was focused ethnography. Participant observation and interviews were used as the primary data collection methods. Fifteen families of children with ADHD were included from somatic and psychiatric hospital clinics. RESULTS: Three main themes emerged from the experiences of the families: When the house of cards collapses in everyday life, Treading water before and after receiving the ADHD diagnosis, and Healthcare as a significant lifeline. CONCLUSIONS: Accessibility to healthcare, trusting relationships and healthcare professionals recognizing how ADHD pervades all aspects of everyday life appear to be important factors in providing a lifeline for parents to help them regain confidence and control in disruptive phases. The parents depend on help from healthcare professionals and family-centred care to manage the complex challenges in everyday life.

Using holistic interpretive synthesis to create practice-relevant guidance for person-centred fundamental care delivered by nurses.

Nursing policy and healthcare reform are focusing on two, interconnected areas: person-centred care and fundamental care. Each initiative emphasises a positive nurse-patient relationship. For these initiatives to work, nurses require guidance for how they can best develop and maintain relationships with their patients in practice. Although empirical evidence on the nurse-patient relationship is increasing, findings derived from this research are not readily or easily transferable to the complexities and diversities of nursing practice. This study describes a novel methodological approach, called holistic interpretive synthesis (HIS), for interpreting empirical research findings to create practice-relevant recommendations for nurses. Using HIS, umbrella review findings on the nurse-patient relationship are interpreted through the lens of the Fundamentals of Care Framework. The recommendations for the nurse-patient relationship created through this approach can be used by nurses to establish, maintain and evaluate therapeutic relationships with patients to deliver person-centred fundamental care. Future research should evaluate the validity and impact of these recommendations and test the feasibility of using HIS for other areas of nursing practice and further refine the approach.

Umbrella review of the evidence: what factors influence the caring relationship between a nurse and patient?

AIMS: The aim of this study was to describe the nurse-patient relationships and to study how caring behaviours were described. The review question was: What factors influence the caring relationship between a nurse and patient? BACKGROUND: There is a growing perception that nurses fail to provide compassionate and competent care. Policy documents prescribe compassion as an essential aspect of care; however, the evidence drawn on remains unclear and without clear applications to practice. DESIGN: Umbrella review methodology, informed by the Joanna Briggs Institute guidelines, was employed and adapted to enable the inclusion of systematic reviews that were of sufficient methodological quality. DATA SOURCES: An extensive PsychInfo, Pubmed, CINAHL, Scopus, WoS and Embase search was conducted for literature published from January 2000-March 2014. Key words included 'nurse', 'patient' and 'relationship' in combination with index terms to find literature published from 2000 onward. REVIEW METHODS: Critical appraisal, data extraction and synthesis were carried out according to existing guidelines for undertaking umbrella reviews. RESULTS: Twelve reviews (representing over 290 studies) were included following critical appraisal. Forty-seven findings were extracted, resulting in 14 categories and six synthesized findings; 'Expectations of the relationships' 'Values', 'Knowledge and skills', 'Communication', 'Context and environment' and 'The impact of the relationship'. CONCLUSIONS: A substantial body of evidence demonstrates that both patients and nurses have expectations about the nature and importance of the caring relationship. Nurses should be mindful that their behaviours and attitudes need to align with what patients value about the relationship. Context shapes the relationship in positive and negative ways.

Child and adolescent mental health nursing seen through a social constructionist lens.

AIM: To discuss the theoretical framework of social constructivism and justify it s appropriateness for and compatibility with an interpretive approach to child adolescent mental health (CAMH) nursing research. BACKGROUND: Recent changes to national nursing legislation in Australia have resulted in the removal of the separate register with regulatory authorities that existed for the specialty of mental health nursing. Aspects of mental health nursing age are not easily defined, with some being tacit. CAMH nursing is a sub-specialty area of mental health in which the role and function of these nurses is also not overtly understood. DATA SOURCE: An interpretive research study was designed to develop a deeper understanding of the role and work of CAMH nurses when working in an inpatient setting. REVEW METHODS: An interpretive enquiry methodology was used fro the study, with three sequential stages of data collection: document analysis, focus group interviews and semi-structured individual interviews. DISCUSSION: Social constructionism was the chosen theoretical framework for this study as it provided a useful lens for interpreting and understanding the work of the CAMH nurse. CONCLUSION: The social constructionist lens was simpatico with mental health nursing, as they both involved making meaning of or assessing information and understanding of social processes and interactions. IMPLICATIONS FOR REEARCH/PRACTICE: A useful lens for further research into mental health nursing practice.

Nurses' perceptions of reasons for missed nursing care in hospitals: a qualitative systematic review protocol.

OBJECTIVE: The objective of this review is to identify and synthesize the best available evidence on nurses' perceptions of the reasons for missed nursing care in hospitals. INTRODUCTION: Missed nursing care in hospitals is a complex and global problem affecting patients, nurses, and the health care system. An in-depth understanding of reasons for missed nursing care is essential to prevent it from happening in hospitals. Nurses' perceptions of reasons for missed nursing care in hospitals are related to the care environment, such as staff levels, nurses' workload, levels of experience and competencies, incomplete communication, and poor teamwork. The reasons are multifaceted, and there is a need to synthesize qualitative evidence on nurses' perceptions of the reasons for missed nursing care in hospitals. INCLUSION CRITERIA: The phenomenon of interest is nurses' perceptions of reasons for missed nursing care, which is defined as care that is either delayed or partially or entirely missed. Studies of nurses with any level of experience, training, or education will be eligible for inclusion. This systematic review will consider qualitative studies that include the perceptions of nurses working in hospital settings, either inpatient or outpatient settings. METHODS: Following an initial search in PubMed, a full search strategy will be conducted in CINAHL (EBSCOhost), PubMed, Embase, Scopus, Google Scholar, and GreyNet International. The JBI approach will inform study selection, critical appraisal, data extraction, and meta-aggregation. Confidence in the findings will be assessed in accordance with the ConQual approach. REVIEW REGISTRATION: PROSPERO CRD42023438198.

Awareness of heart disease and associated health behaviours in a developing country: A qualitative study.

AIM: The aim of this study was to explore awareness of heart disease and associated health behaviours. DESIGN: A qualitative study was conducted using in-depth interviews. METHODS: The study participants were patients with hypertension. Data analysis was guided by Braun and Clarke's steps of thematic analysis and using NVivo12 software. RESULTS: A total of 18 patients with hypertension were interviewed. The patients had poor understanding of heart disease and were not concerned about developing heart disease in the future. Barriers to fruit and vegetable consumption were poor access, cost and sociocultural factors, whereas being busy, poor physical health and lack of access to an exercise facility were barriers to physical activity.

Governance of skilled migration and registration of internationally qualified health practitioners: an Australian policy perspective.

This paper presents a policy perspective on the topical issue of migration and registration of internationally qualified health practitioners (IQHPs), with a focus on international medical graduates and internationally qualified nurses and midwives. Current views, regulatory governance and recommendations affecting skilled migration and registration of IQHPs were examined, specifically whether current and proposed practices are transparent, consistent, equitable, robust, cost-effective and assist in ensuring IQHPs demonstrate the necessary qualifications and experience for protection of the Australian public. The complexity of the current regulatory and administrative application and approval processes for IQHPs seeking to live and work in the Australian healthcare setting provides significant opportunities for future research, particularly those areas of reform under consideration by the Health Ministers' Advisory Council.

The practicability and relevance of developing a yoga intervention for mental health consumers: A qualitative study.

The aim of the study was to understand the perspectives of mental health consumers, staff, and yoga teachers on the characteristics of a yoga-based intervention to be developed for consumers with a long-term mental health condition, in addition to anxiety and/or depression. Two focus groups were held with mental health consumers (n = 8), two focus groups with mental health staff (n = 13) from a metropolitan community mental health setting, and five one-on-one interviews with yoga teachers. Participants were asked about the feasibility and appropriateness of a range of yoga practice features to be tested as a newly developed yoga-based intervention. Thematic analysis was used to identify themes. Findings included the following consumer themes: Mental health understanding and experience of teachers and participants is important, Creating a safe space and Yoga practice elements. Staff themes included Mental health understanding and experience of teachers is important, Environmental design, and Yoga practice elements. Yoga teacher themes included Environmental design and Yoga practice elements. Mental health understanding and experience of the yoga teacher, and trauma-informed care were consistently emphasized by consumers and staff. Teachers focused less on specific mental health considerations, which may be reflective of a broader knowledge gap. Recommendations regarding yoga practice elements, including pre-information, regular and consistent practice, modifications, breathwork, mindfulness and guided practice, and environmental design features, were consistent with current trauma-informed yoga research. Findings will be used to guide the development of a yoga-based intervention for consumers with a long-term mental health condition, in addition to anxiety and/or depression.

Patients' knowledge on cardiovascular risk factors and associated lifestyle behaviour in Ethiopia in 2018: A cross-sectional study.

BACKGROUND: Cardiovascular disease (CVD) is posing a major public health challenge globally. Evidence reports significant gaps in knowledge of cardiovascular risk factors among patients with CVD. Despite the growing burden of cardiovascular disease in developing countries, there is limited data available to improve the awareness of this area, which is crucial for the implementation of prevention programs. METHODS: A cross-sectional survey was conducted in two referral hospitals in Eastern Ethiopia from June-September 2018. Outpatients with a confirmed diagnosis cardiovascular conditions were eligible for participation in the study. A convenience sampling technique was used. The primary outcome of the study was knowledge of cardiovascular risk factors among patients with cardiovascular disease. The knowledge of cardiovascular disease risk factors was measured using a validated instrument (heart disease fact questionnaire). A score less than 70% was defined as suboptimal knowledge. Multivariable linear regression was used to examine the relationship between knowledge of cardiovascular risk factors and explanatory variables. RESULTS: A total of 287 patients were enrolled in the study. Mean age was 47±11yrs and 56.4% of patients were females. More than half of patients (54%) had good knowledge on cardiovascular risk factors (scored>70%), whilst 46% demonstrated suboptimal knowledge levels in this area. Urban residency was associated with higher cardiovascular risk factors knowledge scores, whereas, never married and no formal education or lower education were identified as predictors of lower knowledge scores. There was no statistically significant association between knowledge of cardiovascular risk factors and actual cumulative risk behaviour. CONCLUSION: Almost half of CVD patients in Ethiopia have suboptimal knowledge regarding cardiovascular risk factors. Residence, education level and marital status were associated with knowledge of cardiovascular risk factors. Implementation of innovative interventions and structured, nurse-led lifestyle counselling would be required to effectively guide patients in developing lifestyle modification and achieve sustainable behaviour change.

Analysis of factors influencing length of stay in the Emergency Department in public hospital, Yogyakarta, Indonesia.

BACKGROUNDS: The increasing demand for emergency care may cause prolonged Emergency Department length of stay that has an impact on quality of care. In Indonesia, factors influencing Emergency Department length of stay are difficult to determine. The purpose of the study was to identify factors that contributed to length of stay at tertiary hospital Yogyakarta, Indonesia. METHODS: A descriptive study was conducted with a cross-sectional, retrospective design. Participants (n=139) were patients aged 18 years or over who presented to Emergency Department at tertiary hospital, over seven consecutive days. Data were gathered by reviewing patients' notes using modified data collection tool and by measuring the average time in each stage of Emergency Department patient journey. Mann-Whitney and Kruskal-Wallis tests were utilised to analyse data. RESULTS: The median Emergency Department length of stay was 330min. The acuity level, specialist consultation and need for admission were associated with increased Emergency Department length of stay (p<0.05). Laboratory turn around time (median 58min) and waiting for bed availability (median 167min) contributed to prolonged length of stay, for discharged and admitted patients, respectively. CONCLUSIONS: This study assists in understanding factors that most significantly influence Emergency Department length of stay in an Indonesian hospital and will inform policy makers in development of strategic plans to improve Emergency Department patient flow.

An Investigation of the Needs of Saudi Parents of Preterm Infants in the Neonatal Intensive Care Unit.

Objective This study aimed to identify the needs of Saudi parents who had an infant in a neonatal intensive care unit (NICU) in one of five hospitals in Riyadh City, Saudi Arabia. Materials and methods Data were collected using a questionnaire that comprised questions about demographic characteristics and a modified version of the NICU Family Needs Inventory. A convenience sample of 36 Muslim Saudi mothers and fathers completed a self-reported questionnaire. Parents were asked to rate 52 statements in the NICU Family Needs Inventory as not important, somewhat important, important or very important. Results Saudi parents ranked the needs for assurance, proximity, and information as the most important needs. The comfort and support needs were ranked as the least important. Moreover, the highest top-ranked items were related to assurance of pain infant being treated for (86%), infant expected outcome (83%), and infant being handled gently (83%). Conclusion Nurses should create a relationship with parents and provide them with comprehensible and honest assurance and information. Likewise, it is imperative to provide a high-quality holistic care for parents that relies on their needs assessment.

Cardiovascular risk behaviour is an emerging health issue in developing countries: a cross-sectional study.

BACKGROUND: Low and middle-income countries are facing a high burden of cardiovascular disease while there is limited availability of resources and evidence to educate and modify lifestyle behaviours in the population as well as to guide policy making. AIM: The goal of the present study was to quantify the prevalence of different cardiovascular risk behaviours among patients with known cardiovascular conditions in a developing country. METHODS: A hospital-based cross-sectional survey was conducted in two referral hospitals in eastern Ethiopia. Outpatients who had a confirmed diagnosis of cardiovascular disease were recruited for the study. Data were collected through face-to-face interviews with patients using validated tools. RESULTS: A total of 287 cardiovascular disease patients was recruited, of which 56.4% were women and 90.2% were urban residents. Most patients had inadequate consumption of fruit and vegetables, 51.6% were physically inactive, 20% were current khat chewers, 19% were current alcohol drinkers and only 1% were current smokers. Approximately one-third (30%) of the patients had one of these risk behaviours, more than half (51.9%) had two, 15% had three and 3.1% had four risk behaviours. The majority (70%) of the patients had multiple (more than two) risk behaviours. The prevalence of multiple risk behaviours did not significantly vary with sex, residence and educational level differences (P>0.05). CONCLUSION: Cardiovascular disease patients continue to follow unhealthy lifestyles although they attend follow-up care with a specific focus on risk management. The findings of this study provide evidence for policy makers that health services reform is required to promote healthy lifestyle behaviours for the patients.

Undergraduate nursing students' strategies for coping with their first clinical placement: Descriptive survey study.

BACKGROUND: Clinical placement is an essential component in academic nursing programs to provide nursing students with an opportunity to apply theoretical knowledge to practice. The first clinical placement can be an extremely stressful experience for some nursing students, which may affect their decision to be a nurse. OBJECTIVE: The aim of this study was to identify factors and strategies that enable a positive experience of the first clinical placement for first year nursing students. DESIGN: Mixed methods descriptive survey design. SETTINGS: The study was conducted in a nursing school at one university in South Australia. RESPONDENTS: Respondents were all first year undergraduate nursing students at a higher education facility in South Australia. METHODS: Data collection tool was an online questionnaire including quantitative and qualitative questions. Coping strategies framework informed qualitative analysis. RESULTS: Respondents identified a range of strategies that had enabled them to positively cope with their first clinical placement experience. Strategies included use of debriefing sessions with their clinical lecturers and seeking-out their friends and family to talk about their first clinical placement experiences. Other strategies included being adequately prepared before the clinical placement, identifying and seeking advice from supportive nursing staff and effective communication between nursing schools and clinical institutions about placement arrangements and expectations. CONCLUSIONS: It must not be forgotten how stressful first clinical placements are. This experience will leave a lasting impression on students' introduction to the nursing profession. Sharing coping strategies used by nursing students will assist to provide a positive introduction to nursing practice.

Factors Influencing Registered Nurses' Perceptions of Their Professional Identity: An Integrative Literature Review.

BACKGROUND: This review synthesizes contemporary research investigating the factors influencing RNs' perceptions of their professional identity. METHOD: The method used was an integrative literature review. RESULTS: Factors influencing RNs' perceptions of their professional identity were synthesized into three categories: the self, the role, and the context. The self is the nurse who enacts the role in practice, and the context is the practice setting. Poor alignment of these categories leads to stress, tension, and uncertainty affecting work-force retention. Strong alignment leads to satisfaction with the nursing role, increased staff retention, and improved quality of care and patient outcomes. These three categories should be considered when planning nursing professional development activities. CONCLUSION: This integrative review identified a lack of research addressing how nurses' perceptions of their professional identity change over time. A deeper understanding of their perspective is needed to establish whether career longevity and continued professional development are influences. J Contin Educ Nurs. 2018;49(5):225-232.